A nurse is caring for an immobile client. What is the priority assessment in this client?

Assessment for the presence of peripheral edema

Auscultation of lung sounds

Auscultation of bowel sounds

Assessment of skin turgor

Answer and Explanation

The Correct Answer is B

Choice A reason: This is not the priority assessment because peripheral edema is not a lifethreatening complication of immobility. Peripheral edema is the swelling of the lower extremities due to fluid accumulation. It can be caused by various factors, such as venous insufficiency, heart failure, kidney disease, or medication side effects. The nurse should monitor the client's fluid status and provide elevation and compression therapy as needed.

Choice B reason: This is the priority assessment because lung sounds can indicate the presence of respiratory complications, such as pneumonia or atelectasis, which are common and serious consequences of immobility. Pneumonia is an infection of the lungs that causes inflammation, mucus production, and impaired gas exchange. Atelectasis is the collapse of alveoli, which are the tiny air sacs in the lungs that facilitate oxygen and carbon dioxide exchange. The nurse should auscultate the client's lung sounds regularly and report any abnormal findings, such as crackles, wheezes, or diminished breath sounds. The nurse should also encourage the client to cough, deep breathe, and use incentive spirometry to prevent or treat respiratory problems.

Choice C reason: This is not the priority assessment because bowel sounds can reflect the status of the gastrointestinal system, which is not directly affected by immobility. Bowel sounds are the noises produced by the movement of food and gas through the intestines. They can vary in frequency and intensity depending on the client's diet, activity, and medications. The nurse should auscultate the client's bowel sounds and assess for any signs of constipation, diarrhea, or obstruction. The nurse should also promote the client's bowel function by providing adequate hydration, fiber, and laxatives as ordered.

Choice D reason: This is not the priority assessment because skin turgor can indicate the level of hydration, which is not a primary concern of immobility. Skin turgor is the elasticity of the skin that allows it to return to its normal shape after being pinched or pulled. It can be affected by factors such as age, weight loss, dehydration, or edema. The nurse should assess the client's skin turgor and provide adequate fluids and electrolytes as needed. The nurse should also pay attention to the client's skin integrity and prevent or treat any pressure ulcers or wounds that may result from immobility.

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Correct Answer is C

Explanation

Choice A reason: Culturing the wound is not the nurse's priority assessment for this client, because it is not the most urgent and relevant action. Culturing the wound is a procedure that involves collecting a sample of the wound drainage and sending it to the laboratory for analysis, which can help identify the type and source of infection. Culturing the wound is an important intervention, but it should be done after inspecting the wound and assessing the drainage, and with a medical order and a sterile technique.

Choice B reason: Applying topical ointment to the wound is not the nurse's priority assessment for this client, because it is not the most urgent and relevant action. Applying topical ointment to the wound is a procedure that involves applying a medication or a dressing to the wound site, which can help prevent or treat infection, inflammation, or pain. Applying topical ointment to the wound is an important intervention, but it should be done after inspecting the wound and assessing the drainage, and with a medical order and a clean technique.

Choice C reason: Inspecting the wound and assessing the drainage is the nurse's priority assessment for this client, because it is the most urgent and relevant action. Inspecting the wound and assessing the drainage is a process that involves observing and measuring the wound site and the wound exudate, which can reveal the presence and severity of infection, injury, or healing. Inspecting the wound and assessing the drainage is an essential assessment, as it can guide the diagnosis, treatment, and evaluation of the client's condition.

Choice D reason: Calling the provider to initiate antibiotics is not the nurse's priority assessment for this client, because it is not the most urgent and relevant action. Calling the provider to initiate antibiotics is a communication that involves reporting the client's situation and requesting a prescription for an antimicrobial agent, which can help fight or prevent infection. Calling the provider to initiate antibiotics is an important communication, but it should be done after inspecting the wound and assessing the drainage, and with the necessary data and documentation.

A. Inflammation B. Fever C. Phagocytosis D. Intact skin

Correct Answer is D

Explanation

Choice A reason: Inflammation is not an example of a client's primary defense to infection. Inflammation is a secondary defense to infection, which is activated after the primary defense has been breached. Inflammation is a complex process that involves the release of chemical mediators, the dilation of blood vessels, the increase of blood flow, the migration of white blood cells, and the formation of exudate. Inflammation aims to contain, neutralize, and eliminate the infectious agent and to repair the damaged tissue.

Choice B reason: Fever is not an example of a client's primary defense to infection. Fever is a secondary defense to infection, which is activated after the primary defense has been breached. Fever is an elevation of the body temperature above the normal range, which is usually 36.5 to 37.5 degrees Celsius or 97.7 to 99.5 degrees Fahrenheit. Fever is a systemic response to infection that is regulated by the hypothalamus, which is the part of the brain that controls the body's thermostat. Fever enhances the immune system's activity and inhibits the growth of some pathogens.

Choice C reason: Phagocytosis is not an example of a client's primary defense to infection. Phagocytosis is a secondary defense to infection, which is activated after the primary defense has been breached. Phagocytosis is a process that involves the engulfment and destruction of foreign particles, such as bacteria, by specialized cells, such as macrophages and neutrophils. Phagocytosis is a type of cellular immunity that eliminates the infectious agent and prevents its spread.

Choice D reason: Intact skin is an example of a client's primary defense to infection. Intact skin is the first and most important line of defense against infection, as it forms a physical barrier that prevents the entry of pathogens into the body. Intact skin also has chemical and biological properties that resist infection, such as the acidic pH, the secretion of sebum and sweat, and the presence of normal flora. Intact skin protects the underlying tissues and organs from infection and injury.

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A nurse is caring for an immobile client. What is the priority assessment in this client?

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